Optic Neuropathy Secondary to Polyarteritis Nodosa, Case Report, and Diagnostic Challenges

Systemic Vasculitis and Its Association with the Eye

Vasculitis is a group of diseases characterized by the inflammation of the blood vessel walls. They are classified according to the size of the main vessel involved: large vessel, medium vessel, and small vessel vasculitis. Ophthalmic manifestations are quite common in most of these diseases. Episcleritis and scleritis are the most prevalent manifestation of vasculitis. However, there are certain ocular features characteristic of specific vasculitis entities. Given the severity and potential life-threat of these diseases, knowledge of the ocular manifestations is mandatory for the ophthalmologists.

Polyarteritis nodosa presenting with posterior reversible leukoencephalopathy syndrome

A man in his 20s presented following a generalised tonic-clonic seizure on a background of a recent diagnosis of hepatitis B (HBV). During admission, he was severely hypertensive and imaging findings confirmed a diagnosis of posterior reversible leukoencephalopathy syndrome (PRES). The patient subsequently developed multiorgan involvement with an axonal sensorimotor neuropathy, vascular cutaneous lesions and multiple bilateral renal and splenic infarcts. Based on the 2012 Revised International Chapel Hill Consensus Criteria, a diagnosis of polyarteritis nodosa (PAN) with secondary PRES was made. The patient was given intravenous methylprednisolone, followed by a prolonged course of oral prednisolone, and tenofovir antiviral therapy to target HBV seroconversion. He made a good neurological recovery with resolution of imaging changes. This case highlights the importance of a low threshold for systemic screening for young patients presenting with PRES secondary to uncontrolled hypertension and the importance of viral screening, particularly for HBV.

Anterior ischemic optic neuropathy and cilioretinal artery occlusion secondary to polyarteritis nodosa: A case report

INTRODUCTION

Polyarteritis nodosa is a systemic vasculitis characterized by necrotizing inflammatory lesions affecting the middle and small arteries.

CASE PRESENTATION

A 23-year-old male presented to our ophthalmology clinic with a 1-day history of sudden vision loss in his left eye. Posterior segment examination the left eye showed optic disc borders were faint, hyperemic and fluffy with cilioretinal artery occlusion signs present. Optical coherence tomography revealed the presence of localized intracellular edema from optic disc to superior-hemi of fovea, including fovea. On optical coherence tomography angiography, there was a decrease in vessel density in the superficial and deep capillary plexus in the area matching the cilioretinal artery trace, and choroidal vessel density decreased. Wide field fundus fluorescein angiography showed a large choroidal filling defect (ischemia area) and the cilioretinal artery were not filled in the temporal quadrant. These findings made us think that short ciliary arteries were affected and were the causal of the choroidal ischemia and infarction of optic nerve.

DISCUSSION

PAN-associated choroidal ischemia, cilioretinal artery occlusion and ischemic optic neuropathy are rare. If ischemic retinal condition is seen in young patients, PAN should be considered in the differential diagnosis as it may cause life-threatening complications in its advanced stages.

Neurological Involvement in Primary Systemic Vasculitis

Primary systemic vasculitis can affect every structure in both the central and peripheral nervous system, causing varied neurological manifestations of neurological dysfunction. Early recognition of the underlying causes of the neurological symptoms can facilitate timely treatment and improve the prognosis. This review highlights the clinical manifestations of primary systemic vasculitis in the nervous system.